Patricia Fontaine

Systematic Review of Health Information Exchange in Primary Care Practices

Background: Unprecedented federal interest and funding are focused on secure, standardized, electronic transfer of health information among health care organizations, termed health information exchange (HIE). The stated goals are improvements in health care quality, efficiency, and cost. Ambulatory primary care practices are essential to this process; however, the factors that motivate them to participate in HIE are not well studied, particularly among small practices. Methods: We conducted a systematic review of the literature about HIE participation from January 1990 through mid-September 2008 to identify peer-reviewed and non–peer-reviewed publications in bibliographic databases and websites. Reviewers abstracted each publication for predetermined key issues, including stakeholder participation in HIE, and the benefits, barriers, and overall value to primary care practices. We identified themes within each key issue, then grouped themes and identified supporting examples for analysis. Results: One hundred and sixteen peer-reviewed, non–peer-reviewed, and web publications were retrieved, and 61 met inclusion criteria. Of 39 peer-reviewed publications, one-half reported original research. Among themes of cost savings, workflow efficiency, and quality, the only benefits to be reliably documented were those regarding efficiency, including improved access to test results and other data from outside the practice and decreased staff time for handling referrals and claims processing. Barriers included cost, privacy and liability concerns, organizational characteristics, and technical barriers. A positive return on investment has not been documented. Conclusions: The potential for HIE to reduce costs and improve the quality of health care in ambulatory primary care practices is well recognized but needs further empiric substantiation.

Caffeine-Withdrawal Headache: A Clinical Profile

Abstract Caffeine withdrawal is an important but often overlooked cause of headache. In an ongoing investigation of caffeinism the authors used a questionnaire to determine whether there is a constellation of psychiatric characteristics associated with this type of headache. They found that persons who are susceptible to the syndrome generally report more symptoms of anxiety and depression and rate higher in tests evaluating those parameters; consume more antianxiety agents; feel they are less healthy; and have a significantly higher caffeine intake than persons without caffeine-withdrawal headaches.

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and “Potential Best Practices” to assist with implementation.

Trends in Quality During Medical Home Transformation

PURPOSE We describe changes over time in performance on measures of technical quality and patient experience as a group of primary care clinics transformed themselves into level III patient-centered medical homes. METHODS A group of 21 Minnesota primary care clinics achieving level III recognition as medical homes by the National Committee for Quality Assurance has been tracking a variety of quality and patient satisfaction measures for years. We analyzed trends in these measures and compared them with those of other medical groups in the community to estimate what we might expect as other primary care sites gear up to achieve medical home status. RESULTS The clinics in this group achieved a 1% to 3% increase per year in patient satisfaction and a 2% to 7% increase per year in performance on quality measures for diabetes, coronary artery disease, preventive services, and generic medication use. When compared with the average for other medical groups in the region, the rates of increase were greater for satisfaction, but similar for the quality measures. CONCLUSIONS Achieving medical home recognition was associated with improvements in quality and patient satisfaction for these clinics, but the rate of improvement is slow and does not always exceed levels in the surrounding community in Minnesota (which are also improving). Expectations for large and rapid change are probably unrealistic.

Evaluating Body Mass Index–Specific Trimester Weight Gain Recommendations: Differences Between Black and White Women

INTRODUCTION We compared the gestational weight gains of black and white women with the 2009 Institute of Medicine (IOM) recommendations to better understand the potential for successful implementation of these guidelines in clinical settings. METHODS Prenatal and birth data for 2760 women aged 18 to 40 years with term singleton births from 2004 through 2007 were abstracted. We examined race differences in mean trimester weight gains with adjusted linear regression and compared race differences in the distribution of women who met the IOM recommendations with chi-square analyses. We stratified all analyses by prepregnancy body mass index. RESULTS Among normal-weight and obese women, black women gained less weight than white women in the first and second trimesters. Overweight black women gained significantly less than white women in all trimesters. For both races in all body mass index categories, a minority of women (range 9.9%-32.4%) met the IOM recommended gains for the second and third trimesters. For normal-weight, overweight, and obese black and white women, 49% to 80% exceeded the recommended gains in the third trimester, with higher rates of excessive gain for white women. DISCUSSION Less than half of the sample gained within the IOM recommended weight gain ranges in all body mass index groups and in all trimesters. The risk of excessive gain was higher for white women. For both races, excessive weight gain began by the second trimester, suggesting that counseling about the importance of weight gain during pregnancy should begin earlier, in the first trimester or prior to conception.

Medical Home Transformation: A Gradual Process and a Continuum of Attainment

PURPOSE The patient-centered medical home is often discussed as though there exist either traditional practices or medical homes, with marked differences between them. We analyzed data from an evaluation of certified medical homes in Minnesota to study this topic. METHODS We obtained publicly reported composite measures for quality of care outcomes pertaining to diabetes and vascular disease for all clinics in Minnesota from 2008 to 2010. The extent of and change in practice systems over that same time period for the first 120 clinics serving adults certified as health care homes (HCHs) was measured by the Physician Practice Connections Research Survey (PPC-RS), a self-report tool similar to the National Committee for Quality Assurance standards for patient-centered medical homes. Measures were compared between these clinics and 518 non-HCH clinics in the state. RESULTS Among the 102 clinics for which we had precertification and postcertification scores for both the PPC-RS and either diabetes or vascular disease measures, the mean increase in systems score over 3 years was an absolute 29.1% (SD = 16.7%) from a baseline score of 38.8% (SD = 16.5%, P ≤.001). The proportion of clinics in which all patients had optimal diabetes measures improved by an absolute 2.1% (SD = 5.5%, P ≤.001) and the proportion in which all had optimal cardiovascular disease measures by 4.4% (SD = 7.5%, P ≤.001), but all measures varied widely among clinics. Mean performance rates of HCH clinics were higher than those of non-HCH clinics, but there was extensive overlap, and neither group changed much over this time period. CONCLUSIONS The extensive variation among HCH clinics, their overlap with non-HCH clinics, and the small change in performance over time suggest that medical homes are not similar, that change in outcomes is slow, and that there is a continuum of transformation.

Relationship of clinic medical home scores to quality and patient experience.

We tested the association between medical home characteristics and measures of technical quality and patient experience of care in the 21 clinics of a large medical group that had all achieved level III recognition from the National Committee for Quality Assurance. There was substantial variation among them in both scores on the recognition instrument and in clinic performance measures. However, the few statistically significant associations that were identified disappeared when correction for multiple analyses was applied. We conclude that among primary care clinics recognized as high-level medical homes, the instrument used to assess medical home characteristics cannot differentiate their quality.

Using fuzzy set qualitative comparative analysis (fs/QCA) to explore the relationship between medical "homeness" and quality.

OBJECTIVE Determine, using fuzzy set qualitative comparative analysis (fs/QCA), the relationship between patient-centered medical home (PCMH) systems and quality in 21 NCQA recognized medical homes. DATA SOURCES/STUDY SETTING Primary data collected in 2009, including measures of optimal diabetes care (ODC), preventive services up-to-date (PSUTD), patient experience (PEX), survey data assessing PCMH capabilities (PPC-RS), and other clinic characteristics. STUDY DESIGN Cross-sectional study identifying associations between PPC-RS domains, demographic, socioeconomic, and co-morbidity measures, and quality outcomes. DATA COLLECTION/EXTRACTION METHODS PPC-RS scores were obtained by surveying clinic leaders. PSUTD and ODC scores were obtained from provider performance data. PEX data were obtained from patient surveys. Demographic, socioeconomic, and co-morbidity data were obtained from EMR and census data. PRINCIPAL FINDINGS fs/QCA identified associations between all three outcomes and PCMH capabilities: ODC and team-based care; PSUTD and preventive services systems; and all three outcomes and provider performance reporting systems. Previous statistical analysis of this data had failed to identify these relationships. CONCLUSIONS fs/QCA identified important associations that were overlooked using conventional statistics in a small-N health services data set. PCMH capabilities are associated with quality outcomes.

Is consistent primary care within a patient-centered medical home related to utilization patterns and costs?

The patient-centered medical home (PCMH) is seen as an important vehicle for providing consistent primary care and achieving cost savings through care coordination. We used health plan administrative data to evaluate utilization and cost among enrollees who attended a PCMH compared with those who fragmented their care. Controlling for demographic differences, PCMH attendees made significantly fewer primary care and specialist visits than other groups, and associated professional fees were significantly lower than for enrollees receiving less consistent primary care.

Minnesota's Early Experience with Medical Home Implementation: Viewpoints from the Front Lines.

ABSTRACTBACKGROUNDEvidence is evolving about the impact of patient-centered medical homes (PCMHs) on important outcomes in primary care. Minnesota has developed its own PCMH certification process, envisioned as an all-payer initiative with an emphasis on patient-centeredness, which may add unique experiences and outcomes to the national discussion.OBJECTIVEWe aimed to identify the facilitators and barriers encountered by nine diverse primary care practices selected from the first 80 to achieve PCMH certification in Minnesota.DESIGNThis was a qualitative analysis of semi-structured, in-person interviews.PARTICIPANTSThirty-one administrative and clinical leaders, including clinic managers, physician champions, medical directors, nursing supervisors, and care coordinators participated in the study.KEY RESULTSSix factors emerged as most important to the efforts to become PMCHs: leadership support, organizational culture, finances, quality improvement (QI) experience, information technology (IT) resources, and patient involvement. Facilitators included committed leadership at local and higher levels, prior experience and ongoing support for QI initiatives, and adequate financial and IT resources. Reimbursement was a significant barrier due to perceived inadequacy and inconsistent participation by health plans. The unsuitability of electronic medical records (EMRs) to PCMH documentation requirements likewise presented ongoing challenges. Many interviewees described patient input as helpful to their clinics’ PCMH-related changes and were enthusiastic about their “patient partners.” The majority of interviewees felt that becoming a PCMH was right for patients and was personally worthwhile, even while acknowledging the tremendous effort involved and voicing skepticism about reimbursement over the short term.CONCLUSIONSThe experience of participants in Minnesota’s state-wide initiative to legislate PCMH transformation provides a broad view of facilitators and barriers. Unique facilitators included a requirement for patient involvement, which pushed practices to create patient-centered innovations, and new reimbursement models based on quality indicators for a population. Among barriers were the costs to practices and patients, and EMRs that failed to accommodate PCMH requirements.